Sticking by an Imperfect Standard: Chest Radiography for Pediatric Community-Acquired Pneumonia.

Abstract

* Abbreviations: CAP — : community-acquired pneumonia CXR — : chest radiography ED — : emergency department PCV13 — : 13-valent pneumococcal conjugate vaccine PHIS — : Pediatric Health Information System PIDS/IDSA — : Pediatric Infectious Diseases Society and Infectious Diseases Society of America For decades, chest radiography (CXR) was considered to be the reference standard for diagnosis of community-acquired pneumonia (CAP). Studies of CAP diagnostics in children have used CXR as both a reference standard and an index test, with disagreement over how and when it should be used.1 Although frequently obtained, CXR has low sensitivity and only fair interrater reliability in diagnosing CAP.2 Radiography cannot differentiate bacterial from viral CAP and does not have substantial impact on outcomes.3 Furthermore, access to CXR is limited in many settings. Given these limitations, the 2011 Pediatric Infectious Diseases Society and Infectious Diseases Society of America (PIDS/IDSA) pediatric CAP guideline recommends against routine CXR to confirm suspected CAP in children managed in the outpatient setting, a strong recommendation citing high-quality evidence.4 Despite this, among children 1 to 6 years of age managed as outpatients in the United States from 2008 to 2015, 83% of children with CAP received CXR in the emergency department (ED) compared with 22% in the primary care setting, with no change after guideline publication.5 This suggests that there is still room to improve, especially in the ED. In this issue of Pediatrics , Geanacopoulos et al6 used the Pediatric Health Information System (PHIS), an administrative database, to evaluate CXR use in 30 pediatric EDs from 2008 to 2018 … Address correspondence to Todd A. Florin, MD, MSCE, Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Box 62, Chicago, IL 60611. E-mail: taflorin{at}luriechildrens.org